AMA Journal of Ethics^®

Psychiatrist Stephen Bergman wrote the novel The House of God under the pen name Samuel Shem, basing it on his own experience as a medical intern at Beth Israel Hospital [1]. The novel scandalized senior physicians when it first appeared in 1978 [2]. They could not understand how a work that seemed to glamorize an unprofessional, dehumanizing attitude toward patients (not to mention containing so much bawdy sex) could become an instant hit among their house staff.

To see whether the novel tells us anything about medical education today, we must do what those early critics failed to do: get below the surface to probe the novel’s satiric intent. My colleagues properly trained in literary criticism tell me that one should never assume simplistically that there’s a “moral to the story” of such a complex work. I nevertheless claim that The House of God has a moral, and it is articulated near the end of the book by Chuck, the token African American intern: “How can we care for patients if’n nobody cares for us?” [3]

My reading of the novel is that it depicts a group of interns at a major teaching hospital who end up adopting dehumanized and unprofessional attitudes toward their patients precisely to the degree that the residency experience has treated them in a dehumanized way. If the novel has a hero, it is the Fat Man, the senior resident who tries to help the interns make it through this grueling year. He provides both emotional support and shrewd medical know-how, most of it directly at odds with the academically sophisticated but practically useless teaching of the attending staff, who care only about advancing their academic careers and not at all about the welfare of either the patients or the house staff [4].

Applying the lessons of The House of God today, then, prompts us to ask two questions. First, do we take better care of house staff so that they might then take better care of their patients? And second, if we do, then have those changes actually resulted in better patient care?

It seems immediately clear that many aspects of today’s residency experience are considerably more humane than the world the novel depicts. Most obviously, work-hour limits have done away with much of the grueling call schedule. Most hospitals have hired ancillary staff to help with the “scut work” that used to plague medical students and interns, such as starting IVs, drawing blood, and transporting patients. Residents are paid a higher wage, though I am not sure that the amount does more than correct for inflation. Greater attention is paid to professional behavior at all levels. If a resident today were to call an elderly patient a “gomer” (the derogatory term for demented patients that featured prominently in the novel), I expect that both peers and attendings would strenuously object.

In other ways, however, I am not sure that the house staff experience is more humane and professional than in days of old. Being a resident remains a stressful occupation. In certain respects, it has become more stressful since 1978. As hospital stays shorten, more work needs to be done in a shorter time, and only the sickest patients remain in the hospital. Do we adequately assist our residents in handling that level of stress? A truly humane environment requires opportunities to reflect on one’s experiences and discuss them with others in a supportive environment [5]. How many residencies today offer such opportunities? Are the opportunities offered across all specialties, or only in certain specialties?

The dehumanized world of the House of God interns carried with it at least one half-compensation: the entire world knew what it was like to be a medical intern, so no one expected these interns to perform in social roles outside the hospital—just to fall into bed and sleep. This was only a half-compensation, because, as the novel graphically shows, along with decreased expectations came decreased social support from loved ones, as personal relationships were starved. Today the social support is more robust, but the excuse is gone. Residents have family responsibilities, and no one is willing to cut them any slack—least of all themselves, as today’s young physicians wish, appropriately, to have a life outside medicine. The issues are rendered starker by the more equal gender representation among today’s house staff, quite unlike the almost-exclusively-male world that Shem portrayed in 1978. Is the residency environment doing all it can to assist young physicians in navigating these professional and personal issues? Have we figured out how to take the best care of our patients, to truly care about them, and still fulfill our responsibilities to family and friends and have time for personal nurturing? If we have figured this out, have we helped today’s residents to come to that discovery?

The degree of improvement in the residency environment over the past three decades, in sum, appears to be somewhat mixed. The next question is whether we have reason to believe that residents take better care of patients today, given that at least some of the worst abuses suffered by interns in The House of God seem to have been eliminated. I know of no scientific data that can answer this question, so I must resort to impressions.

I suggest, to stimulate further inquiry, that we are unable to see much overall change in patient care because of two opposing forces. If the only changes that had occurred during this time were the improvements in the residency environment, we might imagine that patient care would have become more humane. But other changes, unfortunately, are driving medicine in a different direction.

The House of God world was already one in which machines and procedures were rapidly replacing whatever was human in the care of patients. Roy Basch, the intern-protagonist in the novel, falls farthest from the way shown him by the Fat Man during his ICU rotation, when he is seduced by the comforting, stress-reducing idea that medicine is nothing but applied physiology and one cares for patients by hooking them up to the right monitors and then reading the numbers off them correctly. The technocracy of medicine, especially within the hospital, has only increased since then. (I do not recall any mention in the novel of a CT scan.)

One piece of that technocracy that especially impacts the life of the resident is the electronic record. I would assume that today’s residents are both far more computer-savvy than their predecessors and fully mindful of the many benefits that an electronic record might achieve in its ideal manifestation. The records that most clinicians work with on a daily basis are, however, notably distant from that ideal, and many are decidedly user-unfriendly. There are two consequences. One is that time that might be spent interacting with patients is instead spent at a keyboard. The other is that the information recorded for each patient is much more likely a matter of cut-and-paste and mouse clicks than a narrative that captures the personhood of the patient and the reality of the illness.

In conclusion, it seems hard to demand that residents ought to be more humane and professional in their interactions with their patients when we have made the entire world of medicine within which they must function steadily less humane and professional in our quest for the magic machine that will eliminate all uncertainty and grant immortality. It is far too soon to put The House of God in the back shelves of the library and declare the task over.